Racial, Ethnic, Sex, and Age Differences in COVID-19 Cases, Hospitalizations, and Deaths Among Incarcerated People and Staff in Correctional Facilities in Six Jurisdictions, United States, March-July 2020.

OBJECTIVES: To examine disparities by sex, age group, and race and ethnicity in COVID-19 confirmed cases, hospitalizations, and deaths among incarcerated people and staff in correctional facilities. METHODS: Six U.S. jurisdictions reported data on COVID-19 confirmed cases, hospitalizations, and deaths stratified by sex, age group, and race and ethnicity for incarcerated people and staff in correctional facilities during March 1- July 31, 2020. We calculated incidence rates and rate ratios (RR) and absolute rate differences (RD) by sex, age group, and race and ethnicity, and made comparisons to the U.S. general population. RESULTS: Compared with the U.S. general population, incarcerated people and staff had higher COVID-19 case incidence (RR = 14.1, 95% CI = 13.9-14.3; RD = 6,692.2, CI = 6,598.8-6,785.5; RR = 6.0, CI = 5.7-6.3; RD = 2523.0, CI = 2368.1-2677.9, respectively); incarcerated people also had higher rates of COVID-19-related deaths (RR = 1.6, CI = 1.4-1.9; RD = 23.6, CI = 14.9-32.2). Rates of COVID-19 cases, hospitalizations, and deaths among incarcerated people and corrections staff differed by sex, age group, and race and ethnicity. The COVID-19 hospitalization (RR = 0.9, CI = 0.8-1.0; RD = -48.0, CI = -79.1- -16.8) and death rates (RR = 0.8, CI = 0.6-1.0; RD = -11.8, CI = -23.5- -0.1) for Black incarcerated people were lower than those for Black people in the general population. COVID-19 case incidence, hospitalizations, and deaths were higher among older incarcerated people, but not among staff. CONCLUSIONS: With a few exceptions, living or working in a correctional setting was associated with higher risk of COVID-19 infection and resulted in worse health outcomes compared with the general population; however, Black incarcerated people fared better than their U.S. general population counterparts.

COVID-19 Burden in Adult Correctional or Detention Facilities and the Surrounding Communities, January 1, 2020-July 20, 2021.

We estimated the COVID-19 burden in adult correctional or detention facilities and associated counties by state, facility jurisdiction, and county urbanicity. COVID-19 cumulative incidence (cases per 1,000 persons) for each U.S. correctional or detention facility and people ages 18 years and older in the associated county was estimated between January 1, 2020 and July 20, 2021. Across 46 U.S. states, 1,083 correctional or detention facilities in 718 counties were included. The median COVID-19 incidence rate was higher in facilities than in associated counties for 42 of 46 states and for all facility jurisdictions and county urbanicity categories. COVID-19 burden was higher in most facilities than in associated counties. Implementing COVID-19 mitigation measures in correctional settings is needed to prevent SARS-CoV-2 transmission in facilities and associated counties.

Tenant-Based Housing Voucher Programs: A Community Guide Systematic Review.

CONTEXT: Unaffordable or insecure housing is associated with poor health in children and adults. Tenant-based housing voucher programs (voucher programs) limit rent to 30% or less of household income to help households with low income obtain safe and affordable housing. OBJECTIVE: To determine the effectiveness of voucher programs in improving housing, health, and other health-related outcomes for households with low income. DESIGN: Community Guide systematic review methods were used to assess intervention effectiveness and threats to validity. An updated systematic search based on a previous Community Guide review was conducted for literature published from 1999 to July 2019 using electronic databases. Reference lists of included studies were also searched. ELIGIBILITY CRITERIA: Studies were included if they assessed voucher programs in the United States, had concurrent comparison populations, assessed outcomes of interest, were written in English, and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing quality and stability, neighborhood opportunity (safety and poverty), education, income, employment, physical and mental health, health care use, and risky health behavior. RESULTS: Seven studies met inclusion criteria. Compared with low-income households not offered vouchers, voucher-using households reported increased housing quality (7.9 percentage points [pct pts]), decreased housing insecurity or homelessness (-22.4 pct pts), and decreased neighborhood poverty (-5.2 pct pts).Adults in voucher-using households had improved health care access and physical and mental health. Female youth experienced better physical and mental health but not male youth. Children who entered the voucher programs under 13 years of age had improved educational attainment, employment, and income in their adulthood; children's gains in these outcomes were inversely related to their age at program entry. CONCLUSION: Voucher programs improved health and several health-related outcomes for voucher-using households, particularly young children. Research is still needed to better understand household's experiences and contextual factors that influence achievement of desired outcomes.

Access to Healthcare and the Utilization of Sexually Transmitted Infections Among Homeless Medicaid Patients 15 to 44 Years of Age.

Homelessness poses a direct threat to public health in the US as many individuals face debilitating health outcomes and barriers to adequate health care. Access to STI care for the homeless Medicaid population of USA has not been well-studied using administrative claims data. Our study aims to compare health services utilization, STI screening and diagnoses among people experiencing homelessness (PEH) vs. those who are non-PEH using ICD10 codes. We used 2019 MarketScan Medicaid claims data to analyze men and women aged 15-44 years with a diagnosis code for PEH (Z59.0), non-PEH (without Z59.0) and assessed their emergency department and outpatient visits and STI/HIV diagnoses and screening rates. We identified 5135 PEH men and 3571 PEH women among 1.3 million men and 2.1 million women in the 2019 US Medicaid database. PEH patients were more likely to have ED visits (94.80% vs 33.04%) and ≥ 20 outpatient clinic visits (60.29% vs 16.16%) than non-PEH patients in 2019. Higher diagnoses were observed for syphilis 1.57% (CI 1.32-1.86) vs 0.11% (CI 0.11-0.11), HIV 3.93% (CI 3.53-4.36) vs 0.41% (CI 0.41-0.42), chlamydia 1.94% (CI 1.66-2.25) vs 0.85% (CI 0.84-0.86) and gonorrhea 1.26% (CI 1.04-1.52) vs. 0.33% (CI 0.33-0.34) (p < 0.0001) among PEH compared to non-PEH. Among PEH, higher STI/HIV diagnoses rates indicate an increase in STI burden and suboptimal STI testing indicates an underutilization of STI services despite having a higher percentage of health care visits compared to non-PEH patients. Focused STI/HIV interventions are needed to address health care needs of PEH patients.

Sexually Transmitted Infection Testing Among Unstably Housed, Sexually Active Persons With Human Immunodeficiency Virus in the United States, 2018-2019.

ABSTRACT: Unstably housed sexually active people with human immunodeficiency virus experience both a high incidence of sexually transmitted infections (STI) and barriers to annual STI screening recommended by Centers for Disease Control and Prevention guidelines. We used Medical Monitoring Project data to describe STI testing among unstably housed people with human immunodeficiency virus by attendance at Ryan White HIV/AIDS Program-funded facilities.

Reddit on PrEP: Posts About Pre-exposure Prophylaxis for HIV from Reddit Users, 2014-2019.

Social media forums provide a window into how gay, bisexual, and other men who have sex with men talk about pre-exposure prophylaxis for HIV prevention (PrEP) outside of research contexts. To examine information exchange about this important pillar of HIV prevention, discussions around PrEP were collected from the r/askgaybros subreddit of the social media site Reddit (2014-2019). Post titles and asks were qualitatively coded to identify themes describing the primary purpose of the post. In all, 1163 PrEP posts were identified, and a 23.3-fold increase in post volume was seen from 2014 (n = 20) to 2019 (n = 466). The most common post type was a mention of PrEP in a post primarily discussing: an assessment of risk after a sexual encounter (19.2%); a sexual or romantic relationship (6.0%); or other (29.3%). Access challenges (19.1%), information seeking (17.5%), and the cultural effects of PrEP on the gay community (16.3%) were other common themes. Posts regarding the initiation of PrEP (11.8%) and PrEP side-effects (9.4%) were moderately represented. Posts addressing promotion, shade, stigma, and usage were infrequent (≤ 5.5% of posts, respectively). Over time, discussion of PrEP has increased exponentially on r/askgaybros, which may reflect the normalization of PrEP. Qualitative analysis of these posts can be a rich source of data for scientists, practitioners, and healthcare providers interested in increasing uptake of PrEP and decreasing barriers to its use.

Mass Testing for SARS-CoV-2 in 16 Prisons and Jails - Six Jurisdictions, United States, April-May 2020.

Preventing coronavirus disease 2019 (COVID-19) in correctional and detention facilities* can be challenging because of population-dense housing, varied access to hygiene facilities and supplies, and limited space for isolation and quarantine (1). Incarcerated and detained populations have a high prevalence of chronic diseases, increasing their risk for severe COVID-19-associated illness and making early detection critical (2,3). Correctional and detention facilities are not closed systems; SARS-CoV-2, the virus that causes COVID-19, can be transmitted to and from the surrounding community through staff member and visitor movements as well as entry, transfer, and release of incarcerated and detained persons (1). To better understand SARS-CoV-2 prevalence in these settings, CDC requested data from 15 jurisdictions describing results of mass testing events among incarcerated and detained persons and cases identified through earlier symptom-based testing. Six jurisdictions reported SARS-CoV-2 prevalence of 0%-86.8% (median = 29.3%) from mass testing events in 16 adult facilities. Before mass testing, 15 of the 16 facilities had identified at least one COVID-19 case among incarcerated or detained persons using symptom-based testing, and mass testing increased the total number of known cases from 642 to 8,239. Case surveillance from symptom-based testing has likely underestimated SARS-CoV-2 prevalence in correctional and detention facilities. Broad-based testing can provide a more accurate assessment of prevalence and generate data to help control transmission (4).

Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review.

CONTEXT: Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration. OBJECTIVES: A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness. DESIGN: A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate. ELIGIBILITY CRITERIA: Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing stability, physical and mental health outcomes, and health care utilization. RESULTS: Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%. CONCLUSIONS: Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.

COVID-19 in Correctional and Detention Facilities - United States, February-April 2020.

An estimated 2.1 million U.S. adults are housed within approximately 5,000 correctional and detention facilities† on any given day (1). Many facilities face significant challenges in controlling the spread of highly infectious pathogens such as SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Such challenges include crowded dormitories, shared lavatories, limited medical and isolation resources, daily entry and exit of staff members and visitors, continual introduction of newly incarcerated or detained persons, and transport of incarcerated or detained persons in multiperson vehicles for court-related, medical, or security reasons (2,3). During April 22-28, 2020, aggregate data on COVID-19 cases were reported to CDC by 37 of 54 state and territorial health department jurisdictions. Thirty-two (86%) jurisdictions reported at least one laboratory-confirmed case from a total of 420 correctional and detention facilities. Among these facilities, COVID-19 was diagnosed in 4,893 incarcerated or detained persons and 2,778 facility staff members, resulting in 88 deaths in incarcerated or detained persons and 15 deaths among staff members. Prompt identification of COVID-19 cases and consistent application of prevention measures, such as symptom screening and quarantine, are critical to protecting incarcerated and detained persons and staff members.

Get In, Get Tested, Get Care: STD Services in Urban Urgent Care Centers.

BACKGROUND: Recent evidence indicates increased use of urgent care centers (UCCs) for sexually transmitted disease (STD) testing. We sought to learn more about STD services in UCCs in a large metropolitan area. METHOD: Using a modified rapid gap assessment approach, we interviewed staff from 19 UCCs in metro Atlanta, GA. The UCCs were identified using two online search engines. We focused on a 50-mile radius around Atlanta. We then excluded duplicates and closed UCCs, and the ones outside Atlanta's five contiguous counties. Using a prioritization process, we visited UCCs in or adjacent to areas with mid to high local STD morbidity, or facilities from which STD cases were reported the year prior. We collected checklist-based data on STD testing, treatment, and preventive services, as well as supportive services (eg, substance use/mental health referrals). Checklist data, notes, and open-ended questions were summarized and analyzed descriptively. RESULTS: All UCCs (n = 19) reported offering basic to comprehensive STD testing. Although most could treat on-site for chlamydia and gonorrhea, most relied on referrals, or prescriptions and "return to facility" practices to treat syphilis. Sources for STD information/management included the health department/Centers for Disease Control and Prevention, online medical sites, and electronic medical record embedded information. Challenges UCCs acknowledged included staying up-to-date with treatment guidance and laboratory reporting requirements, inadequate time for sexual risk reduction counseling, and linking patients with extended care needs (eg, HIV+ case management, supportive services), or following up with patients. CONCLUSIONS: Urgent cares are STD testing resources. Service availability varies, but opportunities exist to enhance STD services in UCC settings and in communities.

Sexually Transmitted Infection Prevalence among Homeless Adults in the United States: A Systematic Literature Review.

BACKGROUND: Homelessness significantly affects health and well-being. Homeless adults often experience co-occurring and debilitating physical, psychological, and social conditions. These determinants are associated with disproportionate rates of infectious disease among homeless adults, including tuberculosis, HIV, and hepatitis. Less is known about sexually transmitted infection (STI) prevalence among homeless adults. METHODS: We systematically searched 3 databases and reviewed the 2000-2016 literature on STI prevalence among homeless adults in the United States. We found 59 articles of US studies on STIs that included homeless adults. Of the 59 articles, 8 met the inclusion criteria of US-based, English-language, peer-reviewed articles, published in 2000 to 2016, with homeless adults in the sample. Descriptive and qualitative analyses were used to report STI prevalence rates and associated risk factors. RESULTS: Overall, STI prevalence ranged from 2.1% to 52.5%. A composite STI prevalence was most often reported (n = 7), with rates ranging from 7.3% to 39.9%. Reported prevalence of chlamydia/gonorrhea (7.8%) was highest among younger homeless adult women. Highest reported prevalence was hepatitis C (52.5%) among older homeless men. Intimate partner violence, injection and noninjection substance use, incarceration history, and homelessness severity are associated with higher STI prevalence. CONCLUSIONS: Homeless adults are a vulnerable population. Factors found to be associated with sexual risk were concurrently associated with housing instability and homelessness severity. Addressing STI prevention needs of homeless adults can be enhanced by integrating sexual health, and other health services where homeless adults seek or receive housing and other support services.

An Intervention for Reducing the Sexual Risk of Men Released From Jails.

Incarceration history can affect sexual health behaviors. A randomized controlled trial of a prevention intervention tailored for post-incarcerated men was administered in a reentry setting. Men ≤45 days post release were recruited into a five-session intervention study. Participants ( N = 255) were assessed and tested for three sexually transmitted diseases (STDs) and HIV at baseline and 3 months post-intervention and followed up for 3 more months. The intervention group's STD risks knowledge ( p < .001), partner communication about condoms ( p < .001), and condom application skills ( p < .001) improved. Although fewer men tested positive for an STD at 3 months post-intervention (10% vs. 8%) and no new HIV cases were found, the finding was not significant. A tailored risk reduction intervention for men with incarceration histories can affect sexual risk behaviors.

Narrative Review: Sexually Transmitted Diseases and Homeless Youth-What Do We Know About Sexually Transmitted Disease Prevalence and Risk?

BACKGROUND: Homelessness affects an estimated 1.6 million US youth annually. Compared with housed youth, homeless youth are more likely to engage in high-risk behaviors, including inconsistent condom use, multiple sex partners, survival sex, and alcohol/drug use, putting them at increased sexually transmitted disease (STD) risk. However, there is no national estimate of STD prevalence among this population. METHODS: We identified 10 peer-reviewed articles (9 unique studies) reporting STD prevalence among homeless US youth (2000-2015). Descriptive and qualitative analyses identified STD prevalence ranges and risk factors among youth. RESULTS: Eight studies reported specific STD prevalence estimates, mainly chlamydia, gonorrhea, and syphilis. Overall STD prevalence among homeless youth ranged from 6% to 32%. STD rates for girls varied from 16.7% to 46%, and from 9% to 13.1% in boys. Most studies were conducted in the Western United States, with no studies from the Southeast or Northeast. Youths who experienced longer periods of homelessness were more likely to engage in high-risk sexual behaviors. Girls had lower rates of condom use and higher rates of STDs; boys were more likely to engage in anal and anonymous sex. Additionally, peer social networks contributed to protective effects on individual sexual risk behavior. CONCLUSIONS: Sexually transmitted disease prevalence estimates among homeless youth fluctuated greatly by study. Sexually transmitted disease risk behaviors are associated with unmet survival needs, length of homelessness, and influence of social networks. To promote sexual health and reduce STD rates, we need better estimates of STD prevalence, more geographic diversity of studies, and interventions addressing the behavioral associations identified in our review.

Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis.

CONTEXT: To improve the quality of depression management, collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management. EVIDENCE ACQUISITION: A team of subject matter experts in mental health, representing various agencies and institutions, conceptualized and conducted a systematic review and meta-analysis on collaborative care for improving the management of depressive disorders. This team worked under the guidance of the Community Preventive Services Task Force, a nonfederal, independent, volunteer body of public health and prevention experts. Community Guide systematic review methods were used to identify, evaluate, and analyze available evidence. EVIDENCE SYNTHESIS: An earlier systematic review with 37 RCTs of collaborative care studies published through 2004 found evidence of effectiveness of these models in improving depression outcomes. An additional 32 studies of collaborative care models conducted between 2004 and 2009 were found for this current review and analyzed. The results from the meta-analyses suggest robust evidence of effectiveness of collaborative care in improving depression symptoms (standardized mean difference [SMD]=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (SMD=0.12); and satisfaction with care (SMD=0.39) for patients diagnosed with depression (all effect estimates were significant). CONCLUSIONS: Collaborative care models are effective in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations. Collaborative care interventions provide a supportive network of professionals and peers for patients with depression, especially at the primary care level.

Designing partner-notification programs to maximize client participation: a factorial survey approach.

BACKGROUND: Factorial survey methods were used to elicit preferences for partner-notification contact, interviewing, and treatment procedures. Most of the experimental alternatives were not rated as highly as standard practice, although there were differences in ratings in accordance with respondents' roles as infected persons or sex partners of infected persons. GOAL: To report on research that identifies the preferences of clients and potential clients for different features of partner-notification programs. STUDY DESIGN: A factorial survey was used to investigate which aspects of current and potential partner-notification programs increase the likelihood of cooperation. Six dimensions defined the hypothetical programs: (1) the sex of the client, (2) the ethnicity of the person meeting with the client,(3) the location of the first meeting with the client, (4) the method of collecting data on sex partners, (5) the contact and referral methods for partners, and (6) how infected sex partners receive medical treatment. Respondents (n = 186) were recruited from a county-run STD clinic, a community clinic, and a community-based organization that primarily provided drug treatment. Each respondent evaluated five different vignettes from two different perspectives: (1) as an infected person and (2) as a sex partner of an infected person. RESULTS: Regression analysis of the responses showed that most experimental approaches to partner notification were negatively evaluated in comparison with evaluations for the conventional program description. There were some differences between the two sets of results, depending on the role of the respondent, suggesting that as sex partners of infected persons, respondents are less concerned about confidentiality at the notification stage but more concerned about it at the treatment stage. Finally, there was no effect of the ethnic or sex match between the disease intervention specialist program staff and the client; this demonstrates that professionalism and training can overcome cultural or ethnic disparities between program staff and clients.